The Need for Alcohol Abuse-Related Education in Nursing Curricula.

Because nurses play a prominent role in primary care, they regularly encounter and attend people with alcohol abuse and dependence problems. For that reason, it is vital that education about alcohol abuse and related problems, which is currently offered in a sporadic manner, becomes an integral element of basic nursing curricula.

P rimary care includes providing patients with guidelines and information for maintaining good health as well as providing the screening, diagnosis, intervention, and treatment of basic health problems, in cluding alcohol abuse and dependence. Nurses play a crucial role in the primary care setting. They assess client needs; formulate and deliver care to individuals and families; and often are responsible for detecting, addressing, and referring pa tients who exhibit alcohol, tobacco, and other drugrelated 1 problems.
Yet basic knowledge about alcohol abuse and its related problems has not been included in general nursing educa tion in any consistent manner. Indeed, significant gaps exist in the content of nursing curricula aimed at educating nurses about substance abuse.
This article briefly reviews the role of nurses in primary care; examines the history of alcohol abuse nursing curricula; describes some model curricula programs; considers the need for clinical placement, preceptorships, and faculty development; and discusses efforts to standardize alco hol abuse curricula. 1 Because the focus of this article is on education about alcohol problems, the terms "alcohol abuse and dependence" and "alcoholrelated problems" are used throughout. However, the curricula discussed here also include information on tobacco, drugs, and drug related problems.

CURRENT NURSING EDUCATION
Basic nursing education now takes place in two major degree programs. The 2year associate degree program teaches nurses to provide direct patient care from a base of scientific knowledge and liberal arts. The 4year baccalaureate degree program prepares nurses to implement prevention, treatment and longterm strategies, such as conducting interviews to obtain pa tients' histories and taking physical as sessments. Nurses with baccalaureate degrees function with more autonomy and have a greater depth of knowledge than do nurses with associate degrees.
A master's degree in a specific content area allows nurses to specialize. Primary care nurse practitioners, nurse midwives, and addictions specialist nurses have master's degrees and are prepared and proficient at nursing diagnosis and health care management within their chosen areas.

ROLES OF NURSES IN P RIMARY CARE
Primary care activities related to alcohol abuse center on the early prevention and intervention of problems and on the iden tification of problems and referral to specialty care.
Such an emphasis on prevention pro vides opportunities for generalist 2 nurses to assume more formal roles in providing primary care. Having a basic nursing edu cation prepares nurses to identify alcohol related problems in patients and to refer them to treatment specialists. For nurse practitioners, the role extends beyond primary care to include secondary care of patients with alcohol abuse and dependence (primary care referring to prevention and health maintenance and secondary care to diagnosis and care of acute illnesses).
A primary care nurse addressing alcohol related problems must have received ade quate education and training to obtain routine alcohol and other drug histories; implement primary prevention strategies, including anticipatory guidance and alcohol abuse education; assess a possible problem with alcohol; formulate a diagnosis of abuse from an analysis of patient assess ments and data collection (e.g., laboratory results); conduct appropriate nursing in terventions (e.g., patient education and nutrition counseling); identify acute alcoholrelated illness and refer patients to physicians or addictions nursing specialists; and continue care in the forms of followup, monitoring, health maintenance, or health care support during recovery. 2 A generalist nurse is educated to address health problems and illnesses for patients of all ages and responses during the patient's life span. These nurses have broadbased experience that is applicable to the entire field of nursing. After the publication of that text, authors of other nursing textbooks in psy chiatric, mental health, and community health nursing began to present chapters on alcohol abuse and dependence, including its health implications and related medical problems. However, the first textbook devoted to the abuse of substances, includ ing alcohol-Substance Abuse, by Bennett and Woolf-was not published until 1991.

SUMMARY OF ALCOHOL AND OTHER DRUG ABUSE CURRICULA FOR NURSES
Even with the inclusion of alcohol abuse content in textbooks, a 1987 survey by Hoffman and Heinemann indicated that little expansion of education about al cohol abuse in nursing curricula had oc curred. Nursing schools averaged only 1 to 5 hours on alcohol abuse education, a dispro portionately small amount given its far reaching health implications. Content related to alcohol abuse and dependence was pre sented primarily in courses on psychiatric or medical nursing, as associated with long term effects and medical complications.

EARLY EFFORTS IN CURRICULUM DEVELOPMENT
In the late 1970's, various efforts recog nized deficits in nursing education for alcoholrelated problems. In conjunction with the National Center for Alcohol Education, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) published The Community Health Nurse and Alcohol Related Problems: A Book of Readings (1978). This was followed by the inclusion of alcoholabuse nursing curricula in the Health Professions Education, Curriculum Resources Series published by NIAAA and the National Institute on Drug Abuse (NIDA).
The publication Alcohol Abuse Cur riculum Guide for Nurse Practitioner Faculty (Hasselblad 1984) describes nurs ing practice based on knowledge of alcohol abuse and dependence in a manner specific to the nurse practitioner's role. The book had its origins in the Conference of Nurse Educators on Alcohol and Drug Abuse held in Colorado Springs in 1982. Each curriculum bases its definition of nursing on the interrelationships of pa tient, nurse, and environment (also see the box on p. 155). In addition, all address the needs of individuals, families, and groups in relation to alcohol abuse at each stage of human growth and development, from fetal life to old age.

DEVELOPING CURRICULUM MODELS
The individual curriculum contains in formation considered essential to the prac tice of the registered professional nurse who is educated at the baccalaureate level, as well as material considered central to the practice of the addictions nursing special ist. Although each curriculum contains more information than can be incorporated into an associate degree program, they all can be adapted to meet the needs of stu dents at levels of practice considered more technical than professional. Furthermore, most modules can be taught separately as continuing education for graduate nurses.

Specifics From Three Schools
Ohio State's College of Nursing curricu lum modules are the most detailed of the three schools, especially in the way that the assessment and organization of content are related to learner needs, educational set ting, and presentation planning. The mod ules cover both beginning and advanced levels of nursing preparation. The faculty at Ohio State also developed an extensive glossary of terms for use in the program.
The University of Connecticut's Nursing Education in Alcohol and Drug Abuse project (Project NEADA) pro duced a twovolume curriculum contain ing eight modules: one for faculty development, three for undergraduates, one for postbaccalaureate students, and three for graduate students. In addition, the faculty work group leading curriculum development produced videocassette tapes to teach techniques for identifying drug and alcohol abusers. These "trigger tapes" provide scenarios and key concepts involved in interviewing patients and obtaining alcohol and other drug histories.
New York University's Substance Abuse Education in Nursing program (Project SAEN) developed 23 modules: 15 at the beginning and advanced undergradu ate levels and 8 at the graduate level. One third of the modules are suitable for teaching students from other health disci plines and also can be adapted for continu ing education. This curriculum includes modules that address the needs of special populations; the use of teams composed of health professionals from medicine and nursing, social workers, and others in addiction treatment; and the relevant re search issues and methodologic considera tions for research in alcohol abuse.

BEYOND DIDACTIC CONTENT
Clinical supervision, preceptorships, and internships are cornerstones for skill building in many health professions. A primary care provider who has skills in assessing alcohol abuse problems is of particular importance as a role model for students. Because patients usually see health care providers for reasons other than their addictions, the skills learned from a good role model are essential. Only sensitive interviewing and knowl edgeable interpretation of screening tools, assessments, and laboratory data will uncover alcohol or other drugs as the cause of the patient's primary complaint.
Model curricula are most effective when they are used in the following ways: • Instructors integrate information on alcohol abuse into other courses, where and when it is germane to course content.
• Faculty with clinical skills in detecting and treating alcohol and other drug abuse and addiction act as role models in care settings.
• Students are placed in clinical settings, such as hospitals or health care facili ties, where patients report use and manifest signs and symptoms of abuse and early, middle, and late stages of alcoholism and other addictions.
• The planning of nursing care includes interventions appropriate to the patient's needs, ranging from health education and prevention for patients at high risk to identification of a problem followed by action, which may include referral to a specialist or counseling by the nurse.

FACULTY DEVELOPMENT PROGRAMS
The goal of faculty development pro grams funded by NIAAA, NIDA, and CSAP is to train groups of medical, nurs ing, social work, and psychology faculty so that they may teach about alcohol and other drug abuse. These programs target faculty members whose specialty areas are other than alcohol abuse, such as family practice, adult health nursing, or psychiatry. Participants learn content on which to develop courses; integrate alco hol and other drug knowledge into stand ing curricula; provide consultation within their schools, universities, and communi ties; and initiate research of significance to their professions and the communities served by their institutions.

SPECIALTY NURSING ORGANIZATION RESOURCES AND CURRICULA
The National Nurses Society on Addic tions (NNSA), the Drug and Alcohol Nurses Association (DANA), and the National Consortium for Chemical Dependency Nurses (NCCDN) promote the roles of nurses in identifying and treating people with alcohol and other drug problems. These organizations con duct continuing education in regional chapters and in the context of annual meetings. NNSA and NCCDN also have developed certifying examinations for nurses specializing in alcohol abuse.
In addition, NNSA published a sixchapter core curriculum of addictions nursing that describes the nursing special ty; reviews etiologic theories; and identi fies nursing activities in assessment, intervention, and longterm recovery. The curriculum includes the definition and interpretation of key concepts related to the addictions and their treatment with an emphasis on nursing roles, research inno vations, and history of the specialty. Two later volumes published by the NNSA-National Nurses Society on Addictions Nursing Care Planning with the Addicted Client (1989)-are more problem orient ed. They give specific guidelines on the use of nationally developed standards for nurses working in treatment programs.
An interorganizational publishing ef fort by the American Nurses Association (ANA), DANA, and NNSA-Standards of Addictions Nursing Practice with Selected Diagnoses and Criteria (1988)outlines an interactive, systematic, prob lemsolving process that can be used to help patients achieve maximum wellness. Such an approach does not differentiate nursing activities according to the educa tion or skill level of the nurse but rather identifies the patient's needs and describes steps taken by the nurse to address them. In such a format, the curriculum and the planning guides are useful resources for practicing nurses and continuing educa tion but are less useful in assisting faculty to integrate alcohol abuse knowledge into beginning and advanced courses and programs.
CSAP also has developed a new train ing system for practicing health profession als, which uses materials from the federally funded curricula and the NNSA core cur riculum as part of their onsite, grassroots training. Courses are designed to assist health professionals in meeting prevention related needs of parent groups, highrisk youth, community workers, and State agency employees. Through this project, school, community health, and occupation al health nurses have access to new infor mation on screening and referral practices.

ROLE OF NURSING ORGANIZATIONS
Educational resources as well as position statements and standards formulated by the ANA, in collaboration with specialty nursing associations, encourage the devel opment of nursing competence with alcoholrelated problems in general prac tice and in primary care delivery.
The ANA currently is attempting to clarify the role of the advanced nurse practitioner in the delivery of primary care. Nurse clinicians, nurse practitioners, and nurse midwives prepared through certifica tion and master's degree education use assessment, care delivery, and case man agement skills, all of which provide av enues for alcohol abuse education and health promotion as well as intervention or referral for abuse and dependence.
Progress is being made toward advanc ing primary care education about alcohol abuse and related problems in nursing curricula. The keys to success lie in the widespread dissemination of teaching materials that support the comprehensive and sensitive assessment of patients and families who are at risk for alcoholrelated problems, especially patients who manifest early or as yet undetected problems.
In addition to developing teaching tools, practitioners, professors, and their associates must have sufficient expertise in the field and be made aware of the need for indepth evaluation of patients with alcohol or other drug problems in clinical care delivery for progress in alcohol abuse education to continue. ■